When the mother calls reporting that the infant is crying and may be in pain, what action should the nurse take first?

When the mother calls reporting that the infant is crying and may be in pain, what action should the nurse take first?

• A. Assess the infant's breathing pattern and incision site.
• B. Offer analgesic medication immediately.
• C. Suggest soothing techniques such as a pacifier.
• D. Check the infant's temperature.

Answer: (A)

In a postoperative infant who just had cleft lip or palate repair, the immediate priority is ensuring an open airway and a secure incision. When the mother reports crying and possible pain, the nurse should first assess the infant’s breathing pattern to confirm adequate ventilation and then inspect the incision site for any bleeding or compromising edema or wound integrity. This check screens for potential airway obstruction or surgical-site problems that could worsen if not addressed right away. Only after confirming the airway and incision are stable should pain management be addressed with analgesia and comforting techniques; giving analgesics first could mask respiratory issues or conceal problems at the repair site. Temperature checks and soothing methods like pacifiers are important components of care but do not take precedence over ensuring a clear airway and a secure incision.

In a postoperative infant who just had cleft lip or palate repair, the immediate priority is ensuring an open airway and a secure incision. When the mother reports crying and possible pain, the nurse should first assess the infant’s breathing pattern to confirm adequate ventilation and then inspect the incision site for any bleeding or compromising edema or wound integrity. This check screens for potential airway obstruction or surgical-site problems that could worsen if not addressed right away. Only after confirming the airway and incision are stable should pain management be addressed with analgesia and comforting techniques; giving analgesics first could mask respiratory issues or conceal problems at the repair site. Temperature checks and soothing methods like pacifiers are important components of care but do not take precedence over ensuring a clear airway and a secure incision.